Navarro College - Associate Degree Nursing

3200 West 7th Avenue

Corsicana, TX 75110
Attn: Betty Shumate, RN, MS

Date Received in Office _________________

Signature of A D N faculty/staff ___________________

ASSOCIATE DEGREE NURSING PROGRAM APPLICATION

For Summer 2013 LVN-RN Bridge Entry
Application Deadline: February 1, 2013 (Postmark Date)
Please include with completed application form
College Transcripts for all colleges attended plus a Navarro College Transcript or Academic
Evaluation. A letter of good standing from Director or Dean or previous RN program, if applicable.
Transcript must document completion of a PN/VN Program.
Name as it appears on your Texas Vocational Nursing License and license expiration date.
A copy of your TEAS results
Declaratory Order(DO) from BON (if applicable) (If DO not available, attach proof of a request.)
Directions: Please type or print legibly in ink.
Name _______________________________________________________________________
Last Name
First
Middle
____________________________________________________________________________
Other names which may appear on academic records
Social Security Number ___________ - ______ - _____________
Mailing Address _______________________________________________________________
________________________________________________________________
City
State
Zip Code
County _________________________
Current Telephone Numbers & E-Mail Address
Home (

)_________ - ______________ Cellular (

)___________ - _______________

Please List Another Telephone # Where You Could Be Reached (

)_______-____________

E-Mail Address _______________________________________________________________

Are you currently enrolled in college classes? Yes _______

No ________

If yes, name of college(s) __________________________________________________

Previous nursing program(s) attended - including your PN/VN Program and any RN programs.
Name of School/College
Type of Program
Dates of Attendance
Date of Graduation
____________________________________________________________________________
____________________________________________________________________________
If you have attended RN nursing programs in addition to your VN program, are you eligible for readmission? Yes ___ No ___ Explain____________________________________________and
attach letter from previous Director or Dean stating eligibility for re-entry to the previous program.
(Or a statement regarding leaving the program in good standing if program does not allow re-entry.)
-continued on back-

Bridge Summer 2013 continued

List all colleges you have attended, including Navarro College and/or any current enrollment.
Name of College/University
City/State
Dates of Attendance
#Hours or Degree
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
TX VN License # ____________________________ Expiration Date __________________
LVN-RN Bridge applicants must have work experience as a LVN to be eligible to start the Summer
Bridge Course.
Do you have the equivalent of nine months of full-time work experience as a LVN at this time?
Yes _______ No ______ Employer _______________________________________________
If NO, will you have the required experience by May, 2013? Explain below:
__________________________________________________________________________
Work Experience - List your work experience as a LVN (GVN) & any other health care work experience.
(Start with most recent)
Employer/Address/Location
Dates (From/To)
Position/Type of Work
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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Signature & Acknowledgment Section- Please read carefully.
I understand if I am offered admission, all conditions of admission including the following must be met as explained in the
Information Session Booklet.
(A) Criminal Background History & Health/Clinical Acknowledgement
(1) A Declaratory Order and approval from Program Director for any positive criminal history. (A positive
finding requires the nursing program to obtain clearance from clinical agencies for future student placement for
clinical experiences.)
(B) Proof of all required vaccinations and other health or clinical forms must be on file at least 3 weeks prior to the first
day of class.
(C) Offers of admission are conditional pending completion of all admission requirements. All deadlines must be met.
(D) I must attend required orientation sessions and respond promptly to all inquiries from the Program Director.
The information I have provided on this application is correct and accurate. I understand that my application must also
include college transcripts and other documents as applicable to be considered for admission to the ADN Program.

___________________________________________________ ___________________
Signature
Date
(Revised 05/2012)
Equal opportunity shall be afforded within the Navarro College system to all employees and applicants for admissions or
employment regardless of race, color, religion, creed, gender, age, national origin, ancestry, disability, marital status, or
veteran status. Navarro College will make reasonable accommodations for persons with disabilities.
Bridge Summer 2013